Transcript Female Infertility

DISORDERS CAUSING INFERTILITY IN
COUPLES
By
Syed Tanveer Abbas Gilani
MBBS, FCPS, Classified Chemical Pathologist
CMH Bahawalnagar
SEQUENCE OF PRESENTATION
Introduction of infertility
Causes, evaluation & diagnostic criteria of male infertility
Causes, evaluation & diagnostic criteria of female infertility
Clinical cases (10 to 20)
What was once an act of private “Love” is now a public act, a
commercial transaction and a professionally managed procedure
Sarah Franklin
INFERTILITY
Infertility is inability to conceive after one year
of unprotected intercourse
Definition
25% of couples experience an episode of
infertility
Primary infertility
Types
Secondary infertility
INFERTILITY
PRIMARY INFERTILITY
• Refers to couples or patients who
had no previous successful
pregnancies
SECONDARY INFERTILITY
• Refers to couples who have
previously conceived, but are
currently unable to conceive
 Hormonal dysfunction of hypothalamic-
pituitary-gonadal axis
PREVALENCE OF INFERTILITY
Prevalence
• World wide 10% to 15%
• Pakistan
21.9%
Relative
abnormalities
• Female partner - 50% (42%)
• Male partner - 40% (26%)
• Both partners - 10% (32%)
Unexplained
infertility
• Approximately 15% to
20%
Ref. Sharlip I, Jarow J, Belker A, Lipshultz L, Sigman M, Thomas A, et al. Best practice policies for male infertility. Fertil Steril 2002;77: 873– 82., Turek PJ. Practical approaches to the
diagnosis and management of male infertility. Nat Clin Pract Urol 2005;2:226–38. 3. Mackay HT. Gynecology. In: Tierney LM, McPhee SJ.Papadakis MA. Current medical diagnosis and
treatment. 42nd ed. New York: Mc Graw-Hill; 2003.p. 699–733.
CAUSES OF MALE INFERTILITY
Figure-1 Different types of disorders causing infertility in 91 (46 %) male patients out of total 200 cases who reported to
CMH Bahawalnagar, as in 109 (54%) patients no demonstrable cause found (n=91).
Primary
testicular failure
Causes of male
infertility
Diagnostic criteria (male infertility)
Duct Obstruction
USG testes
Varicocele
Physical examination, USG testes
Infection
SA = Pus cells > 6/ HPF, motility < 50% after 1 hr or semen C/S
Hypothalamic
dysfunction
FSH < 2 mIU/mL, LH< LLR, testosterone < 7 nmol/L, GnRH stimulation
test (normal /delayed), genetic screening or MRI
Pituitary failure
FSH < 2 mIU/mL, LH< LLR, testosterone < 7 nmol/L, GnRH stimulation
test (abnormal), MRI
Hyperprolactinemias
PRL > 350 mIU/L or MRI
Thyroid disorder
TSH > 4.5 or < 0.4 mIU/L, free T4 < 8 or > 34 pmol/L
Testicular failure
SA =sperm count < 40million/ejac, morphology <30%, testosterone < 7
nmol/L, FSH >120mIU/mL, LH >ULR, HCG stimulation test (abnormal),
Karyotyping, testes FNAC/Biopsy (matura-arrest)
Immunological
SA = motility < 50% after 1 hr, anti sperm Ab = positive
Kartagener syndrome
SA = motility < 50% after 1 hr, genetic screening
Testicular tumors
β HCG > ULR, testes FNAC / biopsy or MRI
Ref. Burtis CA, et al. Tietz fundamentals of clinical chemistry, 6th ed. Saunders, 2008.
Tritos NA. Kallmann Syndrome and Idiopathic Hypogonadotropic Hypogonadism Workup. Medscape. Updated: Jun 4, 2014.
FEMALE INFERTILITY
Female infertility factors are
1.OVARIAN OR HORMONAL FACTORS
a. METABOLIC DISEASE
 Polycystic ovarian syndrome
 Thyroid
 Liver
 Obesity
 Androgen excess
FEMALE INFERTILITY FACTORS
b. HYPERGONADOTROPIC HYPOGONADISM
 Premature ovarian failure
(autoimmune, cytotoxic chemotherapy, tumor)
 Menopause
 Luteal phase deficiency
 Gonadal dysgenesis
 Resistant ovary syndrome
c. HYPOGONADOTROPIC HYPOGONADISM
 Hyperprolactinemia (tumor, drugs)
 Hypothalamic insufficiency (Kallmann syndrome)
 Pituitary insufficiency (tumor, necrosis, stress, anorexia)
FEMALE INFERTILITY FACTORS
d. OVULATORY DYSFUNCTION
 Ovulatory dysfunction manifests itself in presence or absence
of normal menses
 Metabolic diseases affect ovulatory function
 PCOS is the most common cause of anovulation
 CAH should be considered (21-hydroxylase deficiency or 3ßhydroxysteroid deficiency may be present in 26% cases)
FEMALE INFERTILITY FACTORS
2. TUBAL FACTORS
 Occlusion or scarring
 Infectious salpingitis
 Isthmica nodosa
3. CERVICAL FACTORS
 Stenosis
 Inflammation or infection
 Abnormal mucus viscosity
4. UTERINE FACTORS
 Leiomyomata
 Congenital malformations, adhesions
 Endometritis or abnormal endometrium
FEMALE INFERTILITY FACTORS
5. PSYCHOSOCIAL FACTORS
 Decreased libido
 Anorgasmia
6. IATROGENIC
7. IMMUNOLOGICAL
 Anti sperm antibodies
Causes of Female Infertility
Figure-2 Different types of disorders causing infertility in 120 (60 %) female patients out of total 200 cases who reported to CMH
Bahawalnagar, as in 80 (40 %) patients no demonstrable cause found (n=120).
EVALUATION OF FEMALE INFERTILITY
1) Detailed history
2) Physical examination
3) PAP smear
4) Search for tubal patency, endometriosis or adhesions
5) Assessment of ovulation & adequate luteal function
6) Endocrine parameters
(serum FSH, LH, estradiol, progesterone, prolactin,
TSH, free T4, testosterone, DHEAS and 17-OH -progesterone)
7) Immunological parameters (anti sperm antibody)
8) Genetic screening
9) Karyotyping
EVALUATION OF FEMALE INFERTILITY
STEPS OF EVALUATION
1 DETAILED HISTORY
• Irregular periods or no menstrual periods
• Very painful periods
• Endometriosis
• Pelvic inflammatory disease
• More than one miscarriage
1 DETAILED HISTORY (CONT)
Many things can affect a woman's ability to have a
baby. These include:
• Age
• Stress
• Poor diet
• Athletic training
• Overweight or underweight
• Smoking
• Alcohol
• STDs
2.PHYSICAL EXAMINATION
• Body mass index (BMI): kg/m2
• Weight change >10% within past year
• Blood pressure
• Body shape and stature
• Abdominal scars
• Abnormalities in body systems
• Assessment of hirsutism
• Assess secondary sex characteristics
• Record Tanner stage for women not mature
• Examine nipple discharge microscopically
• Examine external genitalia for inflammation
• Clitoral enlargement
• Intact hymen
• Pubic hair distribution
3. PAP SMEAR
 A papanicolaou cervical and vaginal smear (tumor of
squamocoloumnar junction)
 Along with appropriate cervical and endocervical cultures
(infections)
4. USG / HYSTEROSALPANGIOGRAM / LAPROSCOPY
 If ovulation is normal, these tests are needed to search for
tubal patency, endometriosis or adhesions
 Performed between the 7th and 11th day of the cycle
(hysterosalpangiogram)
5. ASSESMENT OF MENSTRUAL STATUS
No amenorrhea or amenorrhea
If no amenorrhea
EVALUATION OF OVULATION
 Serum progesterone levels
Measurement of midluteal (21 day of menses) serum
progesterone
If< 15nmol/l anovulation or leuteal defect
•If >30nmol/l indicates normal ovulation
 Basal body temperature (rapid rise in body
temperature by 0.5ºF, persists through luteal phase)
 Evaluation of LH surge (LH appears in urine just after
serum LH surge & 24 to 36 hrs before ovulation)
5. ASSESMENT OF MENSTRUAL STATUS (cont)
If amenorrhea
Rule out pregnancy by β - HCG
For primary amenorrhea
Asses karyotyping
For secondary amenorrhea
Perform estrogen / progesterone challenge test
Abnormal result shows uterine disease
6. ENDOCRINE PARAMETERS
 Female fertility profile (serum)
 FSH
 LH
 Estradiol (2nd day of menses)
 Progesterone (21 day of menses)
 Prolactin
 GnRH stimulation test
 Other endocrine tests are
 TSH, f T4
 Testosterone & DHEAS (hirsutism)
 17-OH-progesterone (CAH)
 Misc (plasma glucose )
6. ENDOCRINE PARAMETERS (Cont)
Serum prolactin (elevated)
 Suppression of ovulation
Reference: Kronenberg, Melmed, Polonsky, Larsen Williams textbook of endocrinology 11th edition 2008.
6. ENDOCRINE PARAMETERS (Cont)
 If Serum estradiol is low (2nd day of menses)
a.HYPERGONADOTROPIC HYPOGONADISM
 Premature ovarian failure
FSH > 20 mIU/ml, estradiol < 73 pmol/L
 Relative ovarian age
 Serum FSH (rise)
 As FSH increases rate of successful pregnancies decreases

b. HYPOGONADOTROPIC HYPOGONADISM
 Serum FSH < 2 mIU/mL, LH < 2 mIU/mL, estradiol < 110
pmol/L (hypothalamic or pituitary insufficiency)
 Serum prolectin elevated
 TSH increase, f T4 decrease (hypothyroidism)
6. ENDOCRINE PARAMETERS (Cont)
If estradiol / progesterone challenge test is normal
than measure
 Serum FSH and LH if normal/low perform
GnRH or clomiphene tests
 Normal response suggests nutritional,
psychogenic or excess exercise as a
cause of infertility with amenorrhea
 Abnormal response is due to pituitary
failure or delayed in hypothalamic
insufficiency
If serum FSH and LH are elevated
LH<FSH (ovarian failure or resistance)
LH>FSH (2.5) (polycystic ovary syndrome)
7. ENDOCRINE PARAMETERS (Cont)
GnRH stimulation test
 Indication:
 To diagnose hypothalamic pituitary disease in precocious and
delayed puberty in both sexes in children with low basal
gonadotrophins
 Procedure:
 0 min: Take 3ml blood for LH and FSH
 Inj GnRH 100 ug IV (child 2.5 ug/kg body weight to max 100ug)
 After 30 & 60 min : Take 3ml blood for LH and FSH
7. ENDOCRINE PARAMETERS (Cont)
 Interpretation:
 In follicular phase; LH increases 2 fold over baseline or a net
change of at least 10 mIU/ml and FSH 1.5 fold over baseline or
a change of at least 2 mIU/ml
 In luteal phase; LH increases 8 fold over baseline or a net
change of 20 mIU/ml and FSH 1.5 fold over baseline or a net
change of 2 mIU/ml
Reference: (Lufkin et al,1983)
7. ENDOCRINE PARAMETERS (Cont)
Clomiphene stimulation test
 Clomiphene acts by interrupting the negative feedback loop and
thereby stimulating release of gonadotropin from pituitary
Indication
 To diagnose hypothalamic pituitary disease in precocious and
delayed puberty in both sexes in children with low basal
gonadotrophins
Procedure
 100 mg of clomiphene citrate is given for 5 to 7 days
Result
 A doubling of LH and a 20 to 50% increase in FSH are normal,
indicative of an intact hypothalamic-pituitary response
Santen RJ, Leonard JM, Sherins RJ, Gandy HM, Paulsen CA. Short- and long-term effects of clomiphene citrate on the pituitary-testicular axis. J Clin Endocrinol Metab. 1971;33:970-979.
Causes of female
infertility
Diagnostic criteria (female infertility)
Diagnostic criteria (Female Infertility)
Anatomical (obs/adh)
USG / hysterosalpangiogram or laparoscopy
Infections
Endocervical cultures, HVS
PCOS
Obesity, hirsutism, oligomen, LH / FSH > 2.5, testosterone > ULR,
progesterone < 15 nmol/L(21 day), PGR > 11.1 mmol/L, USG ovaries
Hypothalamic
dysfunction
FSH < 2 mIU /mL, LH < 2 mIU /mL, estradiol < 110 pmol/L GnRH
stimulation test (normal /delayed), genetic screening or MRI
Pituitary failure
FSH < 2 mIU /mL, LH < 2 mIU /mL, estradiol < 110 pmol/L, GnRH
stimulation test (abnormal) or MRI
Hyperprolactinemias
Serum PRL > 530 mIU/L or MRI
Thyroid disorder
TSH > 4.5 or < 0.4 mIU/L, free T4 < 8 or > 34 pmol/L
Ovarian failure
Serum estradiol < 73 pmol/L, FSH >20 mIU/ml, LH > ULR, LH < FSH,
or USG, karyotyping
Ovulatory dysfunction
Progesterone<15 nmol/L(21 day of cycle), LH in urine(24-36hr before o)
Androgen excess
Testosterone > 3 nmol/L, DHEAS > 14 umol/L
CAH
17-OH-progesterone>30nmol/L,ACTH stimul test (ab), karyotyping
Immunological
H SA = sperm motility < 50 %1 hr, Anti sperm Ab = positive
Tumors (cervical,
uterine or ovarian)
PAP smear (squamocoloumnar junction), FNAC / biopsy(calposcopic,
hysteroscopic, laparoscopic), CA-125 (ovarian), MRI
Burtis CA, et al. Tietz fundamentals of clinical chemistry, 6th ed. Saunders, 2008. Tritos NA. Kallmann Syndrome and Idiopathic Hypogonadotropic Hypogonadism Workup. Medscape. Updated2014.
Causes
of femaleof
Frequency
Infertility
Dhaliwal
LK et al,
2014 Philippov
OS et
in Our study
disorders
leading
toinfemale
infertility
inal,literature
in India
Western Siberia
No demonstrable cause
9.1
17.5 %
40 %
PCOS
7.2 %
8.4 %
12.5%
Ovulatory dysfunction
26.1 %
21 %
11.5%
Infections
9.2 %
0.4 %
10 %
Obesity
5%
Androgen excess
4%
Hyperprolactinemias
14.3 %
0.8 %
2.5 %
Tubal occlusion
14.2 %
26 %
2%
Fibroid uterus
2%
Endometrial polyp
1.5 %
Endometriosis
3.4
2.3 %
Immunological
1.5 %
1.5 %
Liver disease
1.5 %
1.5 %
PID
1%
Ovarian failure
1%
Thyroid disorder
5.2 %
Pituitary failure
1%
(congenital 3%)
Hypothalamic Dysfunction
Pelvic adhesions
Acquired uterine or cervical
1%
0.5 %
8.4 %
16.8 %
2.3 %
RECOMMENDATIONS
 The prevalence of different conditions leading to infertility differ in
various regions, and management depends on the cause
 It is vital to know the frequency of different causes of infertility in
our setup
CONCLUSION
Genital tract infection is the commonest cause of
infertility, followed by varicocele and immunological
causes in males
PCOS is the commonest problem causing infertility, followed
by ovulatory dysfunction, infection, obesity, androgen
excess, endometriosis and hyperprolactinemias in females
Estimation of semen analysis in male and fertility hormonal
profile in female provides the basis for early diagnosis and
better management of effected patients
Case - 1
 A 19 yr old female. H/O amenorrhea, menarche at age 13 yr,
regular menses till age 18 yr.
 O/E tense, anxious, thin, low weight 38 kg .
 Lab tests
HCG
< 5 mIu/mL (Negative = <5)
LH
1 mIU/mL
(1.7 – 15)
FSH
2.5 mIU/mL (1.4 – 9.9)
E2
95 pmol/l
(73 – 550)
PRL
450 mIU/L
(40 -530)
MRI pituitary fossa (Normal)
Case - 1

Give Diagnosis?
A. Prolectinoma
B. Premature ovarian failure
C. PCOS
D. Hypogonadotropic hypogonadism (anorexia nervosa)
Case -1
 Answer D
 Hypogonadotropic hypogonadism (anorexia nervosa)
Case - 2
 A 27 yr old women. H/O amenorrhea, hirsutism, obesity,
menarche at age 13 yr, regular menses till age 20 yr,
over last 7 yr irregular menses (oligomen--).
 O/E overweight, acne. On USG bil cystic ovaries
 Lab tests
LH
24 mIU/mL (1.7 – 15)
FSH
5.5 mIU/mL (1.4 – 9.9)
E2
140 pmol/L
PRL
375 mIU/L
Testosterone 3.7 nmol/L
(73 – 550)
(40 - 530)
(0.7 – 2.8)
Case - 2
 What is diagnosis?
A.
B.
C.
D.
POF
PCOS
CAH
Liver disease
Case - 2
 Answer B
 PCOS
(LH/FSH ratio >2.5,
hyperandrogenism)
USG
bil
cystic
ovaries,
Case - 3
 A 35-year-old woman. H/O amenorrhea in the previous 6
months, menarche at age 12, two successful pregnancies.
Provera (10mg×5 days) challenge with no subsequent
withdrawal bleeding. She denied visual changes, hot
flashes, or night sweats. No acne, hirsutism, or alopecia.
She did describe galactorrhea, migraine headaches, which
increased in frequency and intensity.
 Laboratory evaluation included
HCG
negative
Prolactin
1050 mIU/L (40–530)
FSH
3 mIU/mL (1.4 – 9.9)
TSH
3 mIU/L
(0.5–5)
Case- 3
MRI of the pituitary fossa-- 2.7cm suprasellar
mass, mild compression of the optic chiasm was noted
The patient had transphenoidal surgery and subsequently
received hormone replacement therapy but her menses did
not resume.
 What is the best choice?
A. Pituitary insufficiency
B. Hypothalamic failure
C. Amenorrhea was secondary effect of prolactin on ovaries
D. Pituitary tumors within the pituitary gland can interfere
directly with gonadotrope function by a mass effect
Case - 3
 Answer D
 Pituitary masses can cause amenorrhea via a mass effect
on the hypothalamus or pituitary stalk as in this case, via
elevated prolactin levels, which result in decreased GnRH
secretion, or through a mass effect on pituitary
gonadotropes
Case - 4
 Which of the following lab tests should you order when a
patient presents with secondary amenorrhea?
A. HCG
B. Prolactin
C. TSH
D. FSH
E. All of the above
Case - 4
 Answer: E
 Pregnancy should always be a consideration in the
workup of secondary amenorrhea, and it is important to
rule out premature ovarian failure. Thyroid dysfunction
(either hypo- or hyper-) can cause menstrual cycle
abnormalities.
Prolactin-secreting
microadenomas
frequently present in this age group in association with
menstrual cycle abnormalities
Case-5
 In a patient with amenorrhea and an elevated prolactin
 which of the following would be the next appropriate
step?
A. Treat with a dopamine against
B. Perform a pituitary MRI
C. Treat with an oral contraceptive pill
D. Perform a mammogram
E. Treat with hormone replacement therapy
Case - 5
 Answer: B
 It is essential that a patient with a persistently elevated
prolactin level have a neuroimaging study to rule out a
large hypothalamic or pituitary tumor. Treatment with a
dopamine agonist will mask the symptoms and needs to
be reserved for use after the cause of the elevated
prolactin has been ascertained. Oral contraceptives and
hormone replacement will likewise obscure the problem
and may mask the appropriate diagnosis
Case-6
 How does hyperprolactinemia cause amenorrhea?
A. Increases GnRH pulse frequency
B. Decreases GnRH pulse frequency
C. Blocks estrogen binding to estrogen receptor
D. Accelerates estrogen metabolism
Case - 6
 Answer: B
 Hyperprolactinemia can interfere with normal LH and FSH
secretion by decreasing GnRH pulse frequency
Case-7
 Which of the following hypothalamic-pituitary disorders
can cause secondary amenorrhea?
A. Hemochromatosis
B. Lymphocytic hypophysitis
C. Sheehan’s syndrome
D. Sarcoidosis
E. All of the above
Case - 7
 Answer: E
 All of the options presented can cause hypothalamic or
pituitary dysfunction and result in secondary amenorrhea
Case - 8
 A 31-year-old woman. H/O infertility for 2-year, menarche at
age of 12 years and regular cycles with intermittent
development of ovarian cysts. The cysts were treated with oral
contraceptive pills (OCPs) from age 24 to 26 yrs. She became
amenorrheic after discontinuing the OCPs 5 years ago. She
noted very occasional hot flashes. Her past medical history
was remarkable for hypothyroidism, diagnosed at age 11
years, for which she took thyroid hormone replacement
 O/E no vitiligo, hirsutism, acne or acanthosis, normal
peripheral visual fields, a 10-g thyroid, no galactorrhea, and
slightly enlarged ovaries
Case - 8
 Laboratory evaluation
TSH
2.27 mIU/L (0.5–5)
Prolactin 320 mIU/L (40–530)
HCG
negative
FSH
19.9 mIU/mL ( 1.4 – 9.9)
Estradiol < 73 pmol/L (73 – 550)
Inhibin B level was very high at 1000 pg/mL (follicular
phase average 173 pg/mL).
 An ultrasound demonstrated multiple ovarian cysts
bilaterally (1 of 10 mm, 3 of 12 mm, and one each at 17,
20, 22, and 30 mm)
Case - 8
 MRI demonstrated a normal pituitary gland
 The patient underwent several cycles of ovulation induction
using a combination of purified LH and FSH, also treated with
estradiol and cyclic progesterone for hormone replacement.
 The patient subsequently developed achy joints and a positive
antinuclear antibody. Ten years later, the patient developed
darkening of the skin and extreme fatigue. ACTH stimulation
test demonstrated baseline cortisol 108 nmol/L, which was
unchanged 1 hour after 250 ug ACTH analogue.
Adrenocorticotropin (ACTH) was elevated at 176 pmol/L. She
was treated with prednisone and fludrocortisone
Case - 8
 What is the most likely cause of infertility?
A. Hypothyroidism
B. PCOS
C. Addison disease
D. Pituitary adenoma
E. Autoimmune ovarian failure
Case - 8
 Answer E
 The patient has polyglandular failure type II with
autoimmune ovarian failure
Case-9
 Which test results are consistent with premature ovarian
failure?
A. FSH 3.2 mIU/mL, LH 0.6 mIU/mL, estradiol <73pmol/L
B. FSH 68 mIU/mL, LH 57 mIU/mL, estradiol < 73pmol/L
C. FSH 9 mIU/mL, LH 56 mIU/mL, estradiol 164 pmol/L
D. FSH 25 mIU/mL, LH 80 mIU/mL, estradiol 1095 pmol/L
Case - 9
 Answer: B
 Results
in A are consistent with hypothalamic
amenorrhea, results in C are consistent with polycystic
ovary syndrome, and results in D are typical day of the LH
surge in a normal menstrual cycle
Case - 10
 When the diagnosis of premature ovarian failure is made,
which additional tests should be ordered?
A. Karyotyping
B. Fragile X premutation screen
C. Adrenal autoantibodies
D. Thyroid autoantibodies
E. All of the above
Case - 10
 Answer: E
 All of these tests are important after an initial diagnosis
has been made
Case -11
 A 56-year-old postmenopausal woman presents with a
history of mild hypertension and a 6-month history of
significant frontal alopecia, hirsutism (Ferriman- Gallwey
score 22) and deepening of her voice. What are the most
important initial test(s)?
A. Total testosterone and urinary 17-ketosteroids
B. Free testosterone
C. Dexamethasone suppression test
D. Total testosterone and insulin-like growth factor I (IGF-I)
Case - 11
 Answer: A
 The development of hyperandrogenic
symptoms in a
postmenopausal woman raises concerns for an androgensecreting tumor of the ovary or, less commonly, the
adrenal. In this woman other concerning signs for
significant hyperandrogenism include deepening of the
voice and the rapid progression of symptoms. The most
useful initial tests in this instance are a total testosterone
and urinary 17-ketosteroids. Ovarian tumors or other
pathologic processes cause secretion of testosterone,
while adrenal tumors often secrete androgen precursors
that are detected as 17-ketosteroids. Some adrenal
tumors make only testosterone
Case - 12
A
36-year-old woman with a 5-year history of
oligomenorrhea, 15-lb centripetal weight gain, treated
hypertension, impaired glucose tolerance, polycystic
ovary morphology on ultrasound, complains of hirsutism,
increased edema and bruising. What is the most
appropriate diagnostic test to perform?
A. DHEAS
B. 24-hour urine free cortisol
C. 17-hydroxyprogesterone
D. TSH
Case - 12
 Answer: B
 In this patient with hirsutism, the signs and symptoms
suggest the presence of Cushing’s syndrome. An
overnight dexamethasone test or a 24-hour urine free
cortisol are the best screening tests
Case - 13
 A 22-year-old college student (BMI 24) is diagnosed with
PCOS based on a history of amenorrhea and biochemical
hyperandrogenemia. Clinically she has mild acne on her
face. She is not currently interested in pregnancy and is
sexually active. What is the most appropriate first-line
treatment option?
A. Lifestyle changes
B. Metformin 500 mg t.i.d.
C. Oral contraceptives
D. Medroxyprogesterone 5mg daily for 14 days per month
E. Spironolactone 100mg daily
Case - 13
 Answer: C
 In this hyperandrogenic patient who is sexually active,
management of cycle irregularity and acne can most
easily be accomplished using oral contraceptives. Oral
contraceptives both suppress gonadotropin stimulation of
ovarian androgen secretion and increase sex hormone–
binding globulin, therefore decreasing circulating free
testosterone
Case-14
 A 49-year-old woman, increased hair growth for the past
6 months that started abruptly; she has male pattern hair
loss, as well. O/E, she has temporal loss of hair and
clitorimegaly.
 Lab tests:
Testosterone 12.5 nmol/L (0.7 – 2.8)
FSH
12 mIU/mL (1.4 – 9.9)
LH
9 mIU/mL (1.7 – 15)
Normal prolactin level
Case - 14
 The next step in the evaluation is one of the following?
A. DHEAS level
B. Repeat FSH and LH levels
C. Fasting blood sugar level
D. Fasting lipid level
E. Computed tomography of adrenal and ovaries
Case - 14
 Answer E
 Computed tomography of adrenal and ovaries (as
testosterone is > 7 nmol/L)
Case - 15
 A 37 yr old women with a history of gonococcal
salpingitis presents with her spouse for evaluation of
infertility.
 What study is most indicated on the initial
evaluation?
A. Basal body temperature record
B. Semen analysis
C. Hysterosalpingogram
D. Endometrial Biopsy
E. A, B & C
Case - 15
 Answer E
 Without evidence of anovulation the endometrial bx is not
indicated. The couple should have A, B, and C
THANK YOU
Dr.Sarma
100